Telehealth Technology-Enabled Patient Care Teams:

A Pilot Program to Expand Access and Improve Coordination and

Quality of Health Care Services in Rural and Underserved Areas of

Virginia

August 22, 2017

Kathy H. Wibberly, PhD

Director, Mid-Atlantic Telehealth Resource Center

UVA Center for Telehealth

Background

• To be established by the Center for Telehealth at the University of Virginia in partnership with the Virginia Telehealth Network

• Two year pilot period: July 1, 2016 – July 1, 2018• $200,000 authorized for Year 1• $190,000 authorized for Year 2

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Background

• Evaluate the success of patient care teams in improving access to care and coordination of care through evaluation of established clinical evidence.

• Report on the results of the pilot program to the Governor and General Assembly by October 15, 2017

• Following is a Progress Update following the 1st year of the pilot.

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Core Element 1

• The Center for Telehealth shall consult all appropriate stakeholders, including but not limited to:

• Medical Society of Virginia • Virginia Hospital and Healthcare Association

• Virginia Council of Nurse Practitioners

• Virginia Community Healthcare Association

• Virginia Academy of Family Physicians

• Virginia Chapter of the American Academy of Pediatrics

• Public and Private Institutions of Higher Education Located in the Commonwealth that Award Medical Degrees

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Update

STEERING COMMITTEE

David Cattell-Gordon UVA Center for Telehealth

Cindy Fagan Virginia Council of Nurse Practitioners

Dorrie Fontaine UVA School of Nursing

Karen Rheuban UVA School of Medicine

Carolyn Rutledge ODU School of Nursing

Mara Servaites Virginia Telehealth Network

Kathy Wibberly UVA Center for Telehealth

ADVISORY COMMITTEE

Rebecca Bates Nurse Practitioner

Del Bolin Edward Via College of Osteopathic Medicine

Diane Boyer UVA School of Nursing

Barbara Brown Virginia Hospital & Healthcare Association

Anita Browning STAR Telehealth

Update

ADVISORY COMMITTEE

Michele Chesser Joint Commission on Health Care

Sandy Chung VA Chapter - American Academy of Pediatrics

Denese Gomes VCU

Pete Hill Nurse Practitioner

Ralston King Medical Society of Virginia

Michelle Kingsbury Virginia Association of Family Practitioners

Michael Weigner Liberty University

Thomas Milam Virginia Tech Carilion

Beth O’Connor Virginia Rural Health Association

Cynthia Romero EVMS

Patty Schweickert UVA School of Nursing

Rick Shinn Virginia Community Healthcare Association

Jerusalem Walker Family Nurse Practitioner

Core Elements 2 and 3

• Include one or more patient care team physicians and one or more licensed nurse practitioners who presently practice in or who relocate to rural or medically underserved areas of the Commonwealth

• Provide technology, training and protocols to participating patient care teams to assist such teams in the delivery of telemedicine services in accordance with the goals of the pilot program

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Update

Phase 1 Objective: To begin implementation of a telehealth enabled patient care team at a minimum of four clinical care sites/settings

Enrolled Phase 1 Pilot Sites Site Type Status

Blue Ridge Medical Center FQHC Active

Adams Compassionate Healthcare Network Free Clinic Active

Harrisburg Community Health Center(began as Elkton Family and Children’s Medical Clinic)

FQHC(Nurse Managed Clinic)

Active

Everhart Primary Care Nurse Managed Clinic Inactive –Internal Issues

Free Clinic of Pulaski Free Clinic Active

Integrative Health Care LLC Nurse Managed Clinic Active, but no Collaborating Physician

VCU Health - Center for Advanced Health Management

Hospital Based Clinic Inactive – NP Left Practice

Update

Lessons Learned

• It is not about the technology, but the people and processes. Deploying the technology and technology training staff was relatively easy.

• For some, the lack of technology was the only barrier. Once they had the technology, they hit the ground running.

• For others, having the technology and training was insufficient to drive utilization. Barriers included things like fear of change, skepticism from board members, and reticence to try something new. In these cases, more intensive personal interaction to get the buy-in and overcome fears was needed.

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Update

• One clinic is expanding its reach by using the technology to connect its current clinic location with new satellite location

• One clinic is using hot spotting for its most at-risk patients to reduce complications from uncontrolled chronic disease and prevent ED visits. Patients are now connecting to providers from home and in conjunction with home visits by APRN/MSW students.

• One clinic is delivering diabetes self management education using the technology.

Creative Use Cases and Emerging Success Stories From This Pilot

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Update

• One clinic has three practice sites, two of which are staffed by NPs. The collaborating physician is being pulled away from clinical practice to travel to the satellite clinic sites. Being able to connect to the NPs using the technology will allow the physician to resume seeing patients in clinic.

Creative Use Cases and Emerging Success Stories From This Pilot

Barriers to utilization of telehealth vary. Affordability and access to technology and training are real barriers…but removing those barriers are

not always sufficient. A personal investment of time and energy is often needed to drive utilization. When funding telehealth efforts, it is

important not to focus only on technology and overlook the necessity of investing in people and processes. Once barriers to utilization are

identified and addressed, success stories abound!

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Update

PHASE 2 Objective: To begin implementation of a telehealth enabled specialty and subspecialty care model at Phase 1 clinic sites

PHASE 3 Objective: Test the scalability of the pilot through expansion of a minimum of 5 additional sites

In Process

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Core Elements 4 and 5

• Include a process for assisting nurse practitioners who seek to participate in the pilot program with identifying and developing a written or electronic practice agreement with a patient care team physician who will provide the required leadership of the patient care team through the use of telemedicine

• Include developing and maintaining a list of physicians who are ready to serve as patient care team physicians and making such a list available to nurse practitioners seeking physicians to serve as a patient care team physician in order to participate in the pilot program and make such a list available on the UVA Center for Telehealth, Virginia Telehealth Network and Department of Health Professions websites.

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Update

NP Practice Agreement Template DevelopedWith Input from Both MSV and VCNP

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Update

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Update

• Is there a problem?• How widespread is

the problem?• What is causing the

problem?

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Update

• VCNP Membership Survey (Email)

• June 21 – July 7, 2017• 357 Responses

• MSV Membership Survey (Email)

• July 13 – August 16, 2017• 73 Responses

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Update

About the NPs

1. What type of NP were you certified/trained

as? (check all that apply)

Response Ratio

Family 65.7%

Pediatric 2.5%

Adult 17.6%

Geriatric 6.7%

Women's Health 4.4%

Neonatal <1%

Acute Care 12.6%

Occupational Health <1%

Psychiatric/Mental

Health 4.7%

Other 1.9%

2. What type of services are you providing?

Response Ratio

Primary Care 50.2%

Specialty Care 44.0%

Mental Health 6.2%

Not applicable 4.5%

Total 100%

5. Is your practice site(s) considered: (Check all that

apply)

Response Ratio

Rural 24.2%

Suburban 48.1%

Urban 30.1%

Not applicable 4.2%

Other 2.8%

Close to 25% of NPs work in rural practice sites compared to only 11% of the nation’s physicians! (http://www.ncsl.org/research/health/meeting-the-

primary-care-needs-of-rural-america.aspx)18

Update

In What Setting(s) Do You Practice?

Hospital/health system 43.9%

FQHC 4.7%

Private practice 29.9%

Nurse managed clinic 2.2%

Public health 4.2%

NP owned practice 3.3%

None, I am retired or otherwise not

working by choice 2.5%

None, I am actively seeking

employment <1%

Other 20.7%

Total Respondents 357

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Update

Do You Currently Have A Collaborative Agreement

Response Ratio

Yes 91.0%

No 3.9%

Not applicable 4.7%

No Responses <1%

With a collaborating physician? With an NP as a collaborating physician?

Only 5.5% of respondents serve as a collaborating physician with an NP who is not in their practice and over 55% of physicians are not in a collaborative relationship with an NP (though some may be collaborating with PAs, nurse midwives, etc.)!

Update

How Was the Collaborative Relationship Established?

My practice assigned a

collaborator to me 79.5%

I was responsible for

finding a collaborator 11.4%

Not applicable 5.1%

Other 7.2%

11.4% of NPs are responsible for finding their own collaborating physician, but only 3.6% of physicians report being approached by an NP to be a collaborator

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Update

In An Average Month, How Much Time Do You Engage…

With your collaborating physician regarding patient care?

Almost never 20.1%

Less than an hour 27.1%

1 hour-5 hours 23.8%

More than 5 hours 22.6%

Not applicable 6.1%

No Responses 0.0%

With your collaborating NP regarding patient care?

Not Sure What To Make Of This Discrepancy!22

Update

Where Is Your Collaborating Physician Located?

In the same facility as I am located (or

within walking distance) 70.5%

Within a 30 minute drive 11.2%

Within an hour drive 7.8%

More than one hour's drive away 2.8%

Not applicable 7.2%

No Responses <1%

How Likely Are You to be Looking for a New

Collaborating Physician in the Upcoming Year?

I'm certain I will 3.6%

Very likely 3.9%

Somewhat likely 8.4%

Not too likely 42.2%

Definitely will not 40.8%

No Responses <1%

Over 16% of NPs are likely to be looking for a new collaborating physician in the upcoming year!

Update

Barriers – Perceived or Real?

10. Since obtaining your NP license,

has there ever been a time where you

felt limited in your ability to work

with patients because you were

unable to find a collaborating

physician?

Number of

Response(s) Response Ratio

Yes 67 18.7%

No 290 81.2%

No Responses 0 0.0%

Total 357 100%

12. In the past 12 months, did you have a

period of time where you felt limited in

your ability to work with patients because

you were unable to find a collaborating

physician?

Number of

Response(s)

Response

Ratio

No 286 80.1%

Yes, but only for a few days 11 3.0%

Yes, for a few weeks 5 1.4%

Yes, for a month or longer 17 4.7%

Not applicable 37 10.3%

No Responses 1 <1%

Total 357 100%

Close to 19% of NPs experienced difficulty finding a collaborating physician, and over 9% experienced this problem in the past 12 months

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Update

Challenges/Barriers

29. If you were to need a new

collaborating physician in the upcoming

year, how confident are you that you

could find one within 30 days?

Response Ratio

I know I could do that 25.4%

I think I could do that 26.6%

I'm uncertain if I could do that 28.5%

I'm pretty sure it would take longer

than 30 days 10.0%

I know it would take a lot longer

than 30 days 8.1%

No Responses 1.1%

“I was running a free diabetes clinic with a collaborating physician until the corporation bought the hospital and practices and the providers became affiliated with the health care organization. There then became a lack of … independent providers in the area that could collaborate with me for the clinic and it had to close”

“I had wanted to open my own practice in an underserved area. I was unable to find a collaborating physician who was willing to work with me at the time. I ended up working further from home in an area that was less needy.”

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Update

Challenges/Barriers

“…some are unwilling to sign off on papers that are required by Medicare because they perceive a shared liability.”

“Restrictions placed on my clinical privileges regarding the requirement for direct physician supervision for all procedures –even those for which I have been specifically educated and trained, per my specialty, to perform.”

“My collaborating physician is required to see all patients I see face to face in a hospital setting… follow up patients included… has led to much duplication of time and services.”

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Update

Challenges/Barriers

“We are willing to add more NPs to our practice, but the legal issues in collaborating with someone far away are too much of a risk for us to take under current laws”

“Many nurse practitioners are working beyond their scope of expertise.”

“NPs do not have the same training as physicians. They are not interchangeable.”

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Update

Challenges/Barriers

Do You Get Paid for Your Time as a Collaborating Physician?

Annual Actual Reported Fees Ranged $0 - $12,000 per year

“[As] I am … looking at opening my own practice in an underserved area, my greatest struggle is the cost I will incur in order to pay someone to be my collaborating physician. Sometimes, it seems that being a collaborating physician is just a way for the physician to make more money.” 28

Update

Challenges/Barriers

15. If you have ever had to find your

own collaborating physician, what

mechanism(s) did you use?

Response Ratio

I asked a physician that was already

affiliated with my practice 14.6%

I contacted a physician with whom I

already had a personal/professional

relationship 13.5%

I asked for referrals from colleagues 3.4%

I was hired to work for the

collaborating physician in his/her

practice 16.0%

I requested assistance from a

professional organization such as

VCNP, MSV, AAFP, etc. <1%

Not applicable 61.6%

Other 3.4%

• Less than 1% requested assistance from a professional organization

• Overall, NPs required to find their own collaborating physician rely largely on those they personally know

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Update

Opportunities

Would You Be Wiling to Collaborate with more NPs in Addition to Your

Current Collaborative Relationship(s)?

Reach out to those who have had good existing relationships with NPs to become champions to their peers and to potentially collaborate with more NPs

“NP quality that I have come across so far has been excellent” “The NPs I work with are

extremely valuable members of our team and embrace the collaborative relationship”

“I employ an NP as an extender and am very impressed with her work and what she has brought to our practice. I think NPs are underutilized in Virginia and could be an important component of reducing health care costs in our state.”

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Update

Opportunities

How would the ability to collaborate with an NP using telehealth impact

your willingness to become a collaborating physician?

Would You Be Interested in Establishing an Agreement with an

NP as a Collaborating Physician?

Identify and reach out to those that are willing and the subset who would be more willing with telehealth

Update

Opportunities

Clarify misconceptions and misperceptions

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In Conclusion

• Barriers to establishing and maintaining relationships with collaborative physicians is a real barrier to practice, limiting the ability to practice for almost 20% of NPs at some point during their career and 9% of NPs in any given year.

• There are physicians willing to collaborate with NPs, and these individuals need to be pro-actively identified.

• A clear mechanism for identifying NPs in need of a collaborator and physicians who are willing to serve as collaborating physicians is needed. However, this may not be sufficient if cost as a barrier to establishing collaborative relationships is not also addressed.

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Preliminary Findings

• One of the greater needs for collaborative care is related to specialty and subspecialty collaborations. This may prove to be an even greater challenge, as has been the case for psychiatry.

• Affordability and access to telehealth technology and training are real barriers…but removing those barriers are not always sufficient. It is important not to focus only on funding and deploying technology and training, but understanding the necessity to make available human resources.

• Once barriers to utilization of telehealth are identified and addressed, we begin to immediately see success stories related to improving access to care coordination and quality of care in rural and underserved populations.

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